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AMERICAN JOURNAL OF OPHTHALMOLOGY

VOLUME 16 DECEMBER, 1933 NUMBER 12

THE MECHANISM OF SENILE CATARACT


DANIEL B. KIRBY, M.D.
NEW YORK, N.Y.
The features of senile cortical cataract are produced by colloidal fluid which has been
extruded from its combination with the lens protein or has been attracted through the
capsule which has been .changed in its permeability. In the incipient stage, this fluid
may produce an ill-defined cortical haze or may diffuse along interfibrillar spaces to reach
the capsule where it collects in the form of the so-called vacuoles or globules, or it may
distend the sutures or interlamellar spaces to form the familiar water-split sutures or
separated lamellae. Senile nuclear cataract represents an excessive sclerosis and de­
hydration of the nuclear and later of the cortical lens material. Study of the formation
of cataract in tetany led to the opinion that a disturbance of the inorganic ions takes
place, which is sufficient to affect the transparency of the labile colloidal solution of the
lens protein. Cataracts in diabetics present features similar to those of the senile cortical
form. The hypothesis is expressed that the various phenomena exhibited in the mechanism
of senile cataract are those of disturbances of permeability. The structures affected in the
eye are the blood vessels and the tissues of the semi-permeable ciliary epithelial mem­
brane, the lens capsule, the lens fibers and the interfibrillar diffusion spaces. The cause
of these disturbances in permeability may be chemical, physical or dependent on metabolic
changes in the general system. The material for this thesis was gathered while the author
was Research Fellow for the American Academy of Ophthalmology and Oto-Laryn-
gology. From the Department of Ophthalmology, College of Physicians and Surgeons,
Columbia University. Read before the Association for Research in Ophthalmology, in
Milwaukee, June 13, 1933.

Many avenues of approach to the Applied anatomy and pathology of the


subject of the etiology of senile cata­ crystalline lens
ract are possible. Fundamental labora­ A. The Aqueous Humor (the vehicle for
tory studies as well as clinical investi­ nutrition and metabolism of the lens).
gations are necessary. I have attempted B. The Capsule (the selective semiper-
to correlate the knowledge that has meable membrane of the lens).
been gained through the research of C. The Epithelium (the formative and se­
creting mechanism of the lens).
others and my own and to develop a D. The Cortex (the more recently formed
concept of what may be called the lens fibers). The Transparency of Tissue.
mechanism of senile cataract. Proper E. The Nucleus (the older and more com­
acknowledgment of all the sources of pact lens fibers).
information is not possible within the The aqueous humor. The aqueous
scope of the paper. Suffice it that part humor is most probably formed by di­
of it is original and part simply an in­ alysis through the semipermeable mem­
terpretation of the ideas of others. brane of the ciliary epithelial cells,
By "the mechanism of senile cata­ which may add a special secretory sub­
ract" is understood the mode of produc­ stance. In the embryo, the anläge of
tion of opacities in the crystalline lens these cells is responsible for the origin
of the elderly. Both the incipient as well and transparency of the lens. The ret­
as the subsequent changes that lead to inal pigment epithelial cells, which are
progressive loss of transparency of the similar in structure, produce a highly
lens may be considered as well as any specialized secretion, the visual purple.
physical or chemical factors that may One may assume that the ciliary epi­
be involved in the process. thelium secretes a substance that con­
A number of interesting points may trols the growth, nutrition, and trans­
be brought out by considering certain parency of the lens. Although not di­
features of the applied anatomy and rectly proved, this is an interesting idea
pathology of the crystalline lens. as a working hypothesis. Failure or im-
1041
1042 DANIEL B. KIRBY

pairment of secretion of this substance Exfoliation of the most superficial


would result in faulty nutrition of the lamella of the anterior lens capsule is
lens with resulting changes which seen frequently enough to be offered as
would affect its transparency. I have evidence that senile changes in the cap­
extracted a substance from the uveal sule do occur. The integrity of the cap­
tissues of the eyes of beef, using the sule is most important ; if it suffers, the
same technic that is used in producing changes in permeability are bound to
insulin, but have made no use of the affect the lens substance.
extract and have not determined the The lens epithelium. The anterior
nature of the substance. and vortex epithelial cells represent
The crystalline lens capsule. The em­ the only nucleated, reproducing indi­
bryonic cuticula is formed as a secre­ vidual elements in the lens. The fibers
tion, or deposit, by the lens epithelial are nonnucleated elements existing as
cells. The adult capsule is formed by parts of the whole, somewhat like the
accretion of layers of similar material red corpuscles of the blood. The ante­
produced by the lens epithelial cells. It rior epithelial cells probably divide and
undoubtedly appears first in semi- move out radially to furnish cells to
liquid form and is forced under capil­ the vortex for the continued formation
lary pressure around and between the of lens fibers. The great proliferative
cortex and the previously existing cap­ activity of the epithelial cells can be
sule, with which latter it fuses. This demonstrated in tissue culture. Ana­
mechanism of formation also explains tomically there is a gradual merging
the thinness of the posterior as com­ from the anterior cuboidal cells to the
pared with the anterior capsule. The equatorial cells. The normal epithelial
capsule acts as a two-way selective cells have great powers of adaptation
semipermeable membrane. The nutri­ as demonstrated by their reactions in
ent and growth materials are brought tissue culture, but, under conditions of
in and the metabolic and break-down disease, this adaptability is impaired.
products of the lens are carried out The crystalline-lens cortex. The cor­
through the capsule in the form of solu­ tex represents the softer, more recently
tion. There are no pores. The degree formed lamellae of lens fibers, the most
and selectivity of permeability of the recent being outermost. The fibers con­
capsule are very important factors in tain more water and the interfibrillar
the health of the lens. diffusion spaces are more open. The
Friedenwald has proved a decrease in relative amounts of soft cortex and hard
permeability progressing with age on a nuclear material vary with the age and
physical basis, a decreased intake of the individual tendency to sclerosis of
fluid through the capsule with normal the nucleus, whether physiological or
output might result in the dehydrated pathological. Conditions that disturb the
sclerosing type of nuclear cataract. A water-content of the lens protein in the
normal intake and decreased output fibers or the substances in the interfibril­
might produce the hydrated form of lar spaces may produce cortical cata­
cortical cataract. ract. The two-way selective permeabil­
Duke-Elder has postulated an in­ ity of the capsule, the water-binding
crease in permeability under certain power of the lens protein, the diffusion
conditions. An increased intake of fluid and absorption systems of the lens fi­
with normal output might result in the bers, all are important in the amount
hydrated form while a normal intake and distribution of the water in the
with increased output might produce lens. The phenomena of senile cortical
the dehydrated nuclear type. cataract are those of hydration of the
Under normal conditions, the lens outer layers of the lens.
can adjust to water-content differences. The transparency of tissue. Embry­
If the" diffusion and absorption systems onic ectoderm from which the lens is
are deficient then differences in water produced is semitransparent. The pro­
content will produce physical changes duction of the transparent tissue of the
in the structure of the lens. cornea and lens requires a special dif-
T H E MECHANISM O F S E N I L E CATARACT 1043

ferentiation. This differentiating factor C. Posterior Cortical Cataract—Its Mech-


must be continued into adult life to D. Anterior and Posterior Subcapsular
Cataracts—Their Mechanism.
maintain transparency. There are three,
possibly more, factors responsible for Senile nuclear cataract. The process
lens transparency: (1) The lens protein of physiologic sclerosis or hardening of
must be of a special chemical combina- the nucleus begins in the embryo and
tin, the nature of which is not thor­ continues throughout the normal life
oughly understood. (2) Each individ­ of the lens. Pathologic sclerosis of the
ual fiber must be transparent. (3) T h e nucleus produces nuclear cataract. The
structure of superimposed fibers and nucleus is harder and drier than nor­
the. intralenticular pressure must be mal. This may be due to insufficient
such as to admit of transparency. Ul- supply of water or abnormal extrusion
tramicroscopic studies have demon­ or abstraction of water. Many other
strated that lens protein, as it exists factors need to be considered but will
in the early embryonic lens, is in a state not be discussed in detail in this paper.
of solution of protein in water, whereas Much light may be had on the mecha­
as it exists in the adult lens fibers, it nism of nuclear cataract from the pa­
is in a state of solution of water in per by Dr. Sanford Gifford presented
protein, a solid solution. The typical at this meeting.
Brownian movement is seen in the em­ Senile cortical cataract. Its mecha­
bryonic lens protein, where the state is nism—incipient stage. In contrast to
that of solution of protein in water. It nuclear cataract, the phenomena of
is necessary to add water or salt solu­ senile cortical cataract are those of hy-
tion to the adult lens protein in order dration and intumescence. The signs of
to separate the particles farther before the incipient stage are :
the Brownian movement can be demon­
strated. Vacuoles or Globules (Subcapsular).
Lamellar Separation.
The crystalline-lens nucleus. The Splitting of the Sutures.
crystalline-lens nucleus represents the Ill-defined Cortical Haze.
dehydrated, hardened, older portions of
the lens. The portions which in the ad­ The Production of Vacuoles or Glob­
vancing periods of life have been sub- ules. Each vacuole or globule repre­
capsular are now pressed to the central sents a collection of colloid fluid similar
zones. These may often be distin­ in physical properties to the aqueous,
guished by their accretion boundaries which has passed along the interfibril­
and suture formations. The hardened lar spaces and has collected at the end
nuclear formations resist the action of where the capillary spaces reach the
the factors which produce cortical cata­ capsule. The fluid may have been ex­
ract, but develop irregularities of inter­ truded from the lens fibers or the lens-
faces, pressure surfaces, colorations and fiber walls may have resisted the ab­
refraction index differences which pro­ sorption of nutrient fluid as it diffused
duce nuclear haze and are part of the along the interfibrillar spaces.
formation of nuclear cataract. The Separation of the Lamellae. The
lamellae are layers of lens fibers. The
same factors that produce the vacuoles
Types of cataract under consideration may cause the separation of the lamel­
A. Senile Nuclear Cataract. lae. Fluid extruded from the deeper lay­
B. Senile Cortical Cataract. ers or diffusing there under conditions
1. Its Mechanism—Incipient Stage: (a) of decreased absorption by the fibers
Production of Vacuoles or Globules; will tend to separate the lamellae. The
(b) Separation of Lamellae; (c)
Water-splitting of Sutures; (d) Ill- currents of diffusion of nutrient fluids
defined Haze in the Cortex. must act under a certain pressure.
2. The Interfibrillar Colloidal Fluid. Water-Splitting of the Sutures. The
3. The Intermediary Stage of Senile lens sutures are formed by the abut­
Cortical Opacities.
4. Mature and Hypermature Stages of ment of the lens fibers or lamellae end
Senile Cortical Cataract. to end at their junction points or lines.
1044 D A N I E L B. KIRBY

These ends are merely in apposition so lens protein coagulum and the attrac­
that excess fluid reaching the suture tion of inorganic and fatty materials.
spaces may tend to separate or split The changed lens protein takes up more
them. The same mechanism may thus water and the lens becomes swollen
be used to explain the production of or intumescent.
vacuoles or globules, lamellar separa­ The mature and hypermature stages
tion, and water-splitting of the sutures. of senile cortical cataract. The rapid
The particular feature produced de­ death of the lens produces autolysis of
pends on the area involved or its re­ the fibers and protein. Much material
ceptivity to pathologic change. It is dif­ goes into solution and is filtered off
ficult to explain the greater frequency through the lens capsule. The lens re­
of appearance of these features of la­ gains its normal size. The hypermature
mellar separation and water-splitting stages of the shrunken and morgagnian
of the sutures in the inferior nasal types are produced by further diges­
quadrants of the lens. tion, extrusion, and absorption of fluid,
The Ill-defined Haze in the Cortex. and also deposit of extraneous material.
This is most probably a cloudy swell­ Posterior cortical cataract. Its mecha­
ing of the lens protein within the fibers nism. This type begins with vacuoles
or a lysis of the fibers with laking of or globules in the posterior cortical lay­
the resulting fluid. In some instances ers. Between and around these features
this may be simply an edema, a physi­ develop irregular deposits of opaque
cal change without any actual dena- material. The posterior cortical area of
turation of the lens protein. The latter the lens is the most poorly nourished.
conception may explain the transient The vitreous is here in contact with
changes in the vision of certain patients the posterior capsule and the ends of
for better or worse when the observer the youngest fibers reach the posterior
is unable to detect any change in the capsule in this area. Toxic substances
physical appearance of the vacuoles, in the vitreous or faulty nutrition of
split sutures, or separated lamellae. the lens will affect the posterior corti­
The interfibrillar colloidal fluid. The cal area first.
water which forms the vacuoles, sepa­ Anterior and posterior subcapsular
rates the lamellae, and splits the su­ cataract. Their mechanism. A rapidly
tures is actually a colloid fluid. I t fol­ progressive form found in complicated
lows certain lines of cleavage both an­ or toxic conditions, either local or sys­
terior and posterior so that symmetrical temic, it is not always a sign of a com­
areas are involved. Whether the small plicated condition, for many of these
amount of fluid that is responsible for cataracts have been removed and ex­
these phenomena is extruded from its cellent results obtained. This type be­
combination with the lens protein or gins with anterior and posterior sub­
whether it is brought in through the capsular vacuoles. These increase in
capsule in excess of the normal amount number and size and there develops a
is unknown. It is certain that in later cloudy swelling of the cortex which
stages, excess fluid is attracted through quickly swells and disintegrates. An
the capsule. intumescent cataract results. This type
The intermediary stage of senile cor­ of cataract is seen in tetany, diabetes
tical opacities. After the incipient stage, in the young, neuro-dermatitis, detach­
the formation of a greater number of ment of the retina, and in other com­
vacuoles, separated lamellae, split su­ plicated conditions of unknown nature.
tures, and diffuse haze mark the prog­
ress of cortical opacities. Morgagnian Applied chemistry in cataract
globules are grayish spherules which A. Deposition of Calcium.
are developed by coagulation of the B. Calcium Metabolism in Senile Cataract.
clear colloid fluid. These are found in C. Cataract of Tetany. Its Mechanism.
D. Cataract and Diabetes.
the split sutures and lakes of broken
lens material. Deposits of opaque ma­ 1. Relation of Human Aqueous Sugar
to Blood Sugar.
terial are made by separation of the 2. Fasting Primary Aqueous in Rela-
THE MECHANISM OF SENILE CATARACT 1045

tion to Primary Aqueous after Food:is reduced below normal. This implies
(a) Sugar Tolerance; (b) Primary a reduction in the aqueous calcium. The
Aqueous in Relation to Blood Sugar;lens normally contains an extremely
(c) Secondary Aqueous Sugar in Re­
lation to Primary Aqueous and small amount of calcium but this is
Blood Sugar. necessary. In two series of experiments,
3. Secondary Aqueous Humor in Cata­ Hess found the lens calcium reduced in
ract and Diabetes. his tetany animals. This reduction is
4. The Mechanism of Cataract in Dia­
betes. sufficient to disturb the equilibrium in
the inorganic elements in the lens and
Deposition of calcium in senile cata­ to cause changes in the sensitive col­
ract. It is well known that the amount loidal solution of the lens protein. The
of calcium in the lens is greatly in­ convulsions may cause some other
creased in cases of senile cataract. Salit change in the aqueous as cataract in
found no increase in the early stages tetany is always associated with con­
of incipient cataract. The deposition is vulsions.
most probably a reaction secondary to Cataract and diabetes. A study of
(1) very slow tissue death, dependent cataracts in diabetics demonstrated
on nutritional deficiency ; (2) degenera­ that the greatest percentage is of the
tion of the lens protein with lipoid and senile cortical type, occurring on the
other by-products ; (3) local concentra­ average ten years earlier than in the
tion of calcium by adsorption to the nondiabetic persons. The rapidly devel­
large molecules of the lipoids; and (4) oping cataract characteristic of diabetes
deposition of the calcium by final is found rarely, usually in adolescent
change in the hydrogen-ion concentra­ patients. The severity of the disease is
tion towards the alkaline side. not a significant factor, as the cataracts
Calcium metabolism of patients with occur with equal frequency in the mild
senile cataract. The serum calcium and in the severe cases, but the greater
level of a series of patients with senile the duration of the disease, the relative­
cataract was normal. An elaborate in­ ly more frequent are the cataracts.
vestigation of the endogenous calcium Retinal and general vascular sclero­
metabolism of these cases proved that sis with hypertension is frequent in
they absorbed, utilized, and excreted diabetes. In cases in which cataract de­
their calcium normally. There was no veloped, retinitis was more frequent
indication of parathyroid or calcium de­ than in those with clear lenses. Retini­
ficiency in these cases. Therefore, senile tis, however, does not necessarily ac­
cataract cannot be caused by calcium company cataract. The height to which
deficiency or excess. the blood sugar may rise does not de­
Cataract of tetany. Its mechanism. termine cataract, as the lenses in
Disturbances of calcium metabolism certain patients have remarkable pow­
with calcium deficiency, absorption, ers of adaptation.
and use is the cause of tetany in in­ The relation of human aqueous sugar
fants and in postoperative cases where to blood sugar. To learn of the impor­
the parathyroids in whole or in great tance of the sugar level alone in the
part have been removed. The wide­ development of cataract in diabetes, the
spread knowledge concerning this and sugar content of the primary aqueous
the measures that are taken to prevent in relation to the sugar content of the
tetany in infants and in post-thyroidec- blood was studied in patients in the
tomy cases, both prophylactic and afternoon out-patient department. The
therapeutic, have resulted in a great de­ primary aqueous considered is the hu­
crease of these cases. mor which normally fills the anterior
In tetany, the blood-serum calcium chamber.

Patients Number Prim y Aqueous Sugar Blood Sugar Ratio


Nondiabetics—Cataract 25 103 120 0.82
. Diabetics—Cataract 23 124 146 0.83
1046 DANIEL B. KIRBY

The fasting primary aqueous in rela­ of cataract and diabetes. Most of these
tion to the primary aqueous after food. cases showed a decreased permeability
Study of Thirteen Cases of Varying of the ciliary membrane or decreased
Sugar Tolerance. The fasting sugar dilatability of the capillaries, if one
showed an average deficit of 20 percent is correct in judging of the results
when compared with the fasting blood. obtained. These conditions may be re­
The rise in comparing the primary sponsible for the faulty nutrition of the
aqueous of one eye with the primary lens. In this manner, the decrease in
aqueous of the other eye was 25 percent permeability in diabetics may be a po­
compared with the rise of 88 percent in tent factor in the cause of cataract.
the blood-sugar values. During the sec­ Some of the cases showed a marked
ond hour, when the nondiabetic blood difference in the behavior of the two
curve was falling, the aqueous con­ eyes in the same individual. This may
tinued to rise. The diabetic cases explain the difference in the develop­
showed a continued rise in aqueous ment of cataract in the two eyes.
sugar even into the third hour, as the The mechanism of cataract in dia­
blood-sugar rise continued into this pe­ betes. When the blood sugar rises, an
riod. adjustment must be made to keep the
The Human Primary Aqueous in Rela­ osmotic pressure of the blood normal.
tion to the Blood Sugar. In the patients The salts of the blood are excreted.
with normal sugar metabolism, the aque­ This produces a more dilute plasma as
ous sugar does not rise to a sufficient the salts which were excreted had more
height to disturb the lens. Transient hy- effect upon the osmotic tension than
perglycaemia cannot be held responsible did the sugar which caused their dis­
for cataract development in elderly placement. The effect upon the aqueous
nondiabetics as the blood sugar has is that of dilution. This osmotically
dropped to the fasting level before the more dilute aqueous is taken up more
slowly diffusing sugar has had time to freely by the lens, the protein of which
affect the sugar level of the aqueous has under certain abnormal conditions
very much. If the elevation of the blood a greater affinity for water. The lens
sugar be prolonged, then the aqueous swells and lenticular myopia is pro­
tends to rise and to equilibrate with duced. Not all diabetics' lenses behave
it. These cases are diabetics and should in this manner, nor do the individuals
be considered and treated as such. In who are affected always respond to
these the height of the aqueous sugar fluctuations in the sugar content of
is undoubtedly one of the factors con­ their blood. There are other factors that
cerned in the formation of cataract. influence the behavior of their crystal­
The Human Secondary Aqueous Su­ line lenses.
gar in Relation to the Primary Aqueous If the process of hydration or water­
and Blood Sugar. The secondary aque­ logging of the lens be more severe than
ous is that humor which forms immedi­ that which the lens can adapt itself to,
ately after the primary aqueous has then droplets of fluid are seen beneath
been removed. It is formed by rapid the lens capsule, the separation of the
transudation from the capillary plasma. lens fibers develops, the splitting of the
There is increased permeability of the sutures occurs, and the fibers may be
semipermeable membrane of the ciliary burst and laked to produce the cloudy
epithelium and dilatation of the capil­ swelling of the cortex. These features
laries of the ciliary body. In the fasting form the cataract. Edema of the ciliary
state, the sugar content approximates and iris epithelia is frequently seen in
that of the primary aqueous, whereas diabetes. It is possible that recovery
after carbohydrate food intake the from these conditions may occur in cer­
sugar content of the secondary aqueous tain cases. But when denaturation and
tends to rise rapidly above that of the coagulation of the lens protein have
primary aqueous of the same eye and occurred and inorganic and fatty de­
to approximate that of the blood. posits made, recovery is not possible.
The secondary aqueous humor in cases Other factors that may account for
T H E MECHANISM O F S E N I L E CATARACT 1047

the formation of cataract in diabetes permeability must be sought more


are (1) the vicious influence of diabetes deeply. They may be chemical, physi­
upon the whole organism, (2) vascular cal, or dependent on metabolic changes
sclerosis, (3) excess acid formation, (4) in the general system. At the present
disturbances of fat metabolism, (5) time knowledge concerning these fac­
disturbances of permeability of the se­ tors is incomplete. Many theories might
lective semipermeable membranes of be elaborated, but none will be found
the ciliary epithelium and lens capsules. to cover all the cases satisfactorily.
The sugar alone in the aqueous, even
though elevated, does not account for Summary
the formation of cataract in diabetes. The mechanism or mode of produc­
Some of the above or an unknown fac­ tion of various features of the differ­
tor may explain the development of ent types of senile cataract has been
cataract in diabetes. analyzed. T h e application of certain
A colloidal solution, such as the lens facts and principles of the anatomy and
protein, needs a certain equilibrium of pathology of the lens to cataract has
the inorganic ions to maintain it in solu­ been made. The important conditions
tion. In diabetes as the blood sugar goes of tetany and diabetes and the relation
up, the inorganic salts including sodium of disturbances of calcium and carbo­
chloride are in part excreted to main­ hydrate metabolism to cataract have
tain the osmotic equivalents of the been studied and certain inferences
blood. This means less of the necessary drawn in regard to senile cataract.
sodium and chloride in the aqueous and
lens. If the amount of sodium and chlo­ Conclusions
ride is reduced below the necessary The most striking feature found in
minimum for the particular colloidal considering the phenomena of the
solution, any globulin will be precipi­ mechanism of senile cataract is that of
tated out. Alpha and beta crystalline disturbance of permeability: 1. of the
are both globulins. ciliary epithelial membrane, 2. of the
crystalline lens capsule, 3. of the inter­
Hypothesis fibrillar diffusion spaces of the lens, and
One hypothesis may be permitted in 4. of the lens fibers themselves. The
this paper. The various phenomena ex­ causes of these changes in permeability,
pressed in the mechanism of senile diffusion, absorption and extrusion of
cataract are those of disturbances of .fluid may be numerous and varied.
permeability. The tissues affected in More fundamental and clinical research
the eye are the ciliary-body blood ves­ is necessary.
sels and tissues, including the selective Acknowledgments are gratefully
semipermeable ciliary epithelial mem­ made to Professor John M. Wheeler
brane, the lens capsule, the lens fibers and to the Fellows of the American
and the interfibrillar diffusion spaces. Academy of Ophthalmology and Oto-
The cause of these disturbances in laryngology.

Bibliography
The following articles, by the author give all the references used in this thesis:
Pathogenesis of senile cataract. Arch, of Ophth., 1932, July, v. 8, pp. 97-119.
A study of standards for judging of the progress or arrest of cataract. Trans. Amer. Acad.
Ophth. and Oto-Laryng., 1927, pp. 203-233.
A study of the nutrition of the crystalline lens. Trans. Amer. Acad. Ophth. and Oto-
Laryng., 1926, pp. 137-153.
The anterior vitreous in health and in disease. Arch, of Ophth., 1932, February, v. 7, pp.
241-258.
Exfoliation of the most superficial lamella of the anterior capsule of the crystalline lens.
Arch, of Ophth., 1930, July, v. 4, pp. 93-95.
Calcium in relation to cataract. 1. In vitro. Arch, of Ophth., 1931, June, v. 5, pp. 856-867.
Calcium in relation to cataract. 2. In vivo. Arch, of Ophth., 1931, June, v. 5, pp. 868-883.
The relation of disturbances of carbohydrate metabolism to cataract. Amer. Acad. Ophth.
and Oto-Laryng., 1932.
1048 DANIEL B. KIRBY

Discussion: Dr. Alan C. W o o d s : of its changes in concentrations also


May I ask Dr. Kirby if changes in re­ lags behind that of the aqueous, a rela­
fraction of myopia are entirely due to tively small change in either would
the water-logging of the lens to the account for considerable ametropia.
exclusion of changes of refractory Friedenwald could not agree with this
aqueous and vitreous with a rapidly hypothesis since the allowable differ­
rising blood sugar? ences in dextrose content of aqueous
Dr. Kirby : I know Dr. Adler has very and vitreous would not account for
beautifully demonstrated the changes more than a fraction of a diopter in re­
in the index of refraction of the aqueous fraction. Both Friedenwald and Duke-
and vitreous that do occur. I think oth­ Elder have reasoned that the fluid in­
ers have pointed out that the amount take on part of the lens is more effec­
of change of refraction that takes place tive in changing the refraction when
in the eyes of certain diabetics cannot the nucleus of the lens is well developed
be satisfactorily explained simply by and while there is still sufficient pliable
the difference in the index of refraction cortex to respond to the hydropic
of the aqueous as compared with that change. Hence these changes are seen
of the lens and vitreous. The phenom­ more often in diabetics at ages between
ena observed in the eyes of diabetics forty and sixty years. In connection
justify the idea that in certain cases at with these theories one must again con­
least we do have swelling of the lens sider the effect of an acidotic condition
and changes in the curvature of the on the water-binding capacity of the
capsule to account for the myopia. protein as well as the effect of changes
Duke-Elder summarized the situa­ in certain cellular constituents, such as
tion by stating that in the course of the a shift between monovalent and diva­
disease with high or increasing sugar, lent cations, or in the lipide and
myopia tends to occur, while with de­ sterol fractions, on cellular permeabil­
creasing sugar after dietary or insulin ity. Severe dietary restrictions have
treatment, hypermetropia tends to oc­ been considered as one of the causes
cur. It does not happen in every dia­ of changes in index of refraction. Jen­
betic case and is quite variable even in sen reports a case of transitory impair­
the same individual. The site of the ment in refraction due to a strict reduc­
change in focus is most probably the ing diet in a nondiabetic woman of
lens, the capsule and substance of sixty-five. In this case, change in re­
which are freely permeable to dextrose. fraction set in three times and each time
The fleeting character of the changes after an essential change in diet.
does not disprove the theory that dex­ Changes in refraction may be ac­
trose is the responsible factor as it dif­ counted for even though the sugar in
fuses in and out of the lens quite free­ the aqueous does not rise to any degree.
ly. In this connection one must also In a number of our patients we found
take into account the products of dex­ that the aqueous sugar did not follow
trose catabolism in the lens and their the blood sugar. In fact, there was often
effect on the water-binding capacity of a marked difference. In all the cases
the lens protein. Another hypothesis is examined there was a tendency of the
that the changes in refraction are due aqueous sugar to approximate that of
to a change in the index of refraction the blood in the fasting state. In the
of the media depending upon the varia­ diabetics the dextrose concentration of
tion in sugar concentration. If the the aqueous was often considerably
change is regarded as affecting all the elevated. If the refraction of the lens
media, then the necessary conditions varied directly with the sugar content
are impossible, but Adler has postu­ of the fluids surrounding it, one would
lated a differential change in concentra­ expect a hyperopic change in these pa­
tion in the aqueous as compared to the tients which, however, is not always
vitreous. The sugar concentration of present.
the vitreous is considerably lower than Dr. W o o d s : I quite agree with Dr.
that of the aqueous and since the rate Kirby and I further ask him if he knows
THE MECHANISM OF SENILE CATARACT 1049

any swelling of the lens that does oc­ Chairman Parker : Do you agree ?
cur under the influence of a rise of Dr. Woods: I agree.
blood sugar. Have you experimented by placing
Dr. Kirby: I think the best definite lenses in sugar solution?
evidence is the fact that we have the Dr. Kirby : No, that necessarily does
appearance of globules, vacuoles, and not cover all the features you have in
the separation of the sutures and the diabetes. You do not have the semiper-
lamellae in the extreme cases. I do not meable membranes of the ciliary body,
believe we can, as you know, Dr. you do not have the circulation of the
Woods, bring out any physical evidence blood and the changes that take place
or any practical evidence of this in the contents of the blood. You will
change, but considering all the different agree that you need a more complex
explanations, I think you will agree set-up for your experiment than simply
that this is the more practical. placing the lens in sugar solution.